ment [101]. In a prospective study of 41 patients, a combination of PDT and radiotherapy versus radiotherapy alone were compared. Results showed airway obstruction completely opened in 10% of patients treated with radiation therapy, versus 70% of patients treated with the combination of PDT and radiotherapy. Twenty percent of patients did not have any response to either treatment [102].

A group of ten patients with inoperable non-­ small cell carcinoma and a different degree of tracheobronchial obstruction (86 ± 2%) showed a response of 50% or more in 4 patients and 50% or less in 6 patients. However, all patients improved their symptoms, especially cough. Adverse effects included burns in two patients and one moderate edema [58].

PDT in Combination with Other Techniques for Advanced-Stage Non-small Cell Lung Cancer

Both Nd-YAG laser application and PDT are useful in centrally located, obstructive malignant lesions of the airways. The choice of one method over the other depends upon many factors, such as a patient’s preferences, his/her general health status, and physician’s experience.

Historically, it had been accepted that the combination of chemotherapy and radiotherapy is the choice for advanced lung cancer treatment [103]. However, new combinations are accepted as a valid therapy in the palliative management of non-small cell carcinoma. PDT treatment associated with external radiotherapy seems less harmful than the combination of radiotherapy and

brachytherapy. It is reasonable to assume that PDT produces less toxicity and it can be a valid option in the multidisciplinary palliative treatment. We compared a group of patients with central airway obstruction due to non-small cell carcinoma treated with only external radiotherapy (30 Gy in ten sessions) with patients treated with radiotherapy and PDT. Results revealed better symptom control with radiological and functional improvement when both methods were combined [104].

Prospective studies of Freitag and colleagues have suggested combining PDT and brachytherapy for palliative control of endobronchial non-­ small cell carcinomas according to the principle of synergistic action. Control at 24 months was successful and without complications [105].

However, the sequence of the treatment combination is not well de ned for PDT and radiotherapy or brachytherapy (PDT before or after the associated treatment).

Endoscopic techniques could be helpful in choosing the best sequence of application. AFB can evaluate super cial tumor extension along the bronchial mucosa and detect early lesions or local recurrence. EBUS can evaluate the real tumor extension in the bronchial wall and allows a better selection of patients.

PDT was deemed well-tolerated and effective as part of a multi-modal treatment for endobronchial non-small cell lung cancer (NSCLC) in another retrospective study with 9 patients, 8 males and 1 female aged 52–73 who received combined PDT and HDR for endobronchial cancers. Intervention was with HDR (500 cGy to